Get Doh 4362 Form

The Doh 4362 Form is a crucial document for EMS agencies seeking to verify their medical director's oversight and compliance with state regulations. This guide provides a step-by-step process for successfully filling out the form online, ensuring that users can navigate the requirements with ease.

Follow the steps to complete the Doh 4362 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of your EMS service in the designated field. Ensure the name is accurate to represent your organization clearly.
3. Input the agency code number in the provided space. This identifier is essential for your service's records.
4. Select the appropriate service type by checking the box for either Ambulatory, ALSFR, or BLSFR, marking the category of your emergency service.
5. Fill in the name of the service CEO in the designated field to identify the executive overseeing the agency.
6. Provide the name of the Service Medical Director and ensure that it is spelled correctly for official documentation.
7. Enter the New York State physician's license number corresponding to the Medical Director to verify their credentialing.
8. If applicable, include the Albuquerque/ALSFR service controlled substance license number along with its expiration date.
9. After completing the information fields, review the Medical Director's affirmation of compliance section and ensure that the Medical Director is aware of their responsibilities.
10. The Medical Director should sign in the designated field and provide the date of signature to validate the document.
11. Once all components of the form are filled out appropriately, save the changes, and you may download, print, or share the completed form as necessary.

Complete your Doh 4362 Form online today to ensure compliance and accurate oversight for your EMS agency.